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Based upon observation and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

See the individually and below cited K-tags:

K-324